Please help, newbie with insurance problems!!!

Hi Everyone, I took the first big step and wrote my pcp asking for a referral for wls. She doesn't think I'll qualify even though my bmi is 44.9 with a couple of two-three comorbidities. Does anyone have any suggestions? I guess I have to wait a couple of weeks until the referral coordinator gets back to me. This is Group Health Insurance by the way. I would love to hear from other Group Health consumers to see how they got approved. From what I understand if I get approved, I would be having the laproscopic Roux-en-Y Bypass procedure. Thanks in advance for your help. Lexie

Hi Lexie! I have Group Health insurance. Don't be surprised if you get denied the first attempt. They deny just about everyone. I can tell you that with your BMI and even one comorbidity, you SHOULD be approved. You just have to show proof. I know that when I was approved, they had just gotten rid of the requirement that you had to have participated in a 6-month supervised diet in the last 3 years. I don't know if they have brought that requirement back now since things have changed. And yes, you will be approved for the RNY procedure. Contact Harriet at the Eastside Hospital for the right referral form. There is one that has to be filled out and sent in with your PCP referral. Her email is [email protected] She will have all the pertinent info for you, including the criteria for approval. Don't give up. BE PERSISTANT WITH THEM!!! I had to appeal the initial denial with lots of back up information on previous diet attempts, health issues, copies of testing results, etc. And a nice letter from my PCP. If you need any help, I am happy to help you. Just email me privately if you don't want to discuss this stuff here. Take care and GOOD LUCK! Lori

Hi Lorlee, Thanks for your reply, I'm going to email Harriet today. I don't think my doctor was that interested in helping me get approved. But, I'm ready to be denied the first time. What kind of proof do they want? I guess if I have to fight to have the surgery I will. I have been on Weigh****chers off and on for the last two years, I wonder if that would count towards a supervised diet. Thanks so much for the information, Lexie

Weigh****chers ABSOLUTELY counts! Especially if you have proof! When I say proof for your BMI and comorbs I mean that your doc has to have that in his/her referral letter. Stating the fact that your BMI is over 40 and what conditions you have been DIAGNOSED with. Harriet is AWESOME! She will give you all of the info you need. And I can send you a copy of the letter I wrote to the insurance company. I copied alot of it from a sample letter here on this site. Very thorough and heartfelt. Worked for me! And all of it was the truth. Lori